Current through Register Vol. 35, No. 11, June 11, 2024
Section 7.7.2.40 - ADDITIONAL REQUIREMENTS FOR PSYCHIATRIC HOSPITALSA. Additional Medical Record Requirements. The medical records maintained by a psychiatric hospital shall document the degree and intensity of the treatment provided to individuals who are furnished services by the facility. A patient's medical record shall contain:(1) identification data, including the patient's legal status;(2) the reason for treatment or chief complaint in the words of the patient, when possible, as well as observations or concerns expressed by others;(3) the psychiatric evaluation, including medical history containing a record of mental status and noting the onset of illness, the circumstances leading to admission, attitudes, behavior, estimate of intellectual functions, memory functioning, orientation and an inventory of the patient's personality assets recorded in descriptive fashion;(4) social services records, including reports of interviews with patients, family members and others and an assessment of home plans, family attitudes and community resource contacts as well as social history;(5) a comprehensive treatment plan based on an inventory of the patient's strengths and disabilities, which shall include:(a) at least one diagnosis;(b) short-term and long-range goals;(c) the specific treatment modalities used; and(d) the responsibilities of each member of the treatment team.(6) staff shall plan, implement and revise, as indicated, a written, individualized treatment program for each patient based on: (a) the degree of psychological impairment and appropriate measures to be taken to relieve treatable distress and to compensate for nonreversible impairments;(b) the patient's capacity for social interaction;(c) environmental and physical limitations such as seclusion room or restraints, required to safeguard the individual's health and safety with an appropriate plan of care; and(d) the individual's potential for discharge and successful care management on an outpatient basis.(7) the documentation of all active therapeutic efforts and interventions;(8) progress notes related to treatment needs and the treatment plan are reviewed, revised and recorded at least weekly as the status of the patient requires by the physician, nurse, social worker and staff from other appropriate disciplines involved in active treatment modalities, as indicated by the patient's condition; and(9) discharge information, including: (a) recommendations from appropriate services concerning follow-up care; and(b) at least one diagnosis.B. Additional Treatment Plan and Staffing Requirements.(1) The hospital shall have enough staff with appropriate qualifications to carry out an active plan of psychiatric treatment for individuals who are furnished services in the facility.(2) The treatment of psychiatric inpatients shall be under the supervision of a qualified physician who shall provide for taking an active role in an intensive treatment program.(3) If non-psychiatric medical and surgical diagnostic and treatment services are not available within the facility, qualified consultants or attending physicians shall be immediately available if a patient should need this attention, or an adequate arrangement shall be in place for immediate transfer of the patient to an acute-care hospital.(4) Nursing services shall be under the supervision of a professional registered nurse qualified to care for psychiatric patients and, by demonstrated competence, to participate in interdisciplinary formulation of individual treatment plans, to give skilled nursing care and therapy, and to direct, supervise and educate others who assist in implementing the nursing component of each patient's treatment plan.(5) Professional registered nurses and other nursing personnel shall participate in inter-disciplinary meetings affecting the planning and implementation of treatment plans for patients, including diagnostic conferences, treatment planning sessions and meetings held to consider alternative facilities and community resources.(6) Psychological services shall be under the supervision of a psychologist licensed under the Professional Psychologists Act, Section 61-9-1 through 61-9-18 NMSA 1978. There shall be enough psychologists, consultants and support personnel qualified to carry out their duties to: (a) assist in essential diagnostic formulations;(b) participate in program development and evaluation;(c) participate in therapeutic interventions and in interdisciplinary conferences and meetings held to establish diagnoses, goals and treatment programs.(7) The number of social work staff qualified to carry out their duties shall be adequate for the hospital to meet the specific needs of individuals patients and their families and develop community resources and for consultation to other staff and community agencies. The social work staff shall:(a) provide psychosocial data for diagnosis and treatment planning;(b) provide direct therapeutic services; and(c) participate in interdisciplinary conferences and meetings on diagnostic formulation and treatment planning, including identification and use of alternative facilities and community resources.(8) The number of qualified therapists and therapist assistants shall be sufficient to provide needed therapeutic activities, including, when appropriate, occupational, recreational, and physical therapy, to ensure that appropriate treatment is provided to each patient.(9) The total number of rehabilitation personnel, including consultants, shall be sufficient to permit appropriate representation and participation in inter-disciplinary conferences and meetings, including diagnostic conferences, which affect the planning and implementation of activity and rehabilitation programs.7.7.2.40 NMAC - Rp, 7.7.2.40 NMAC, 06-15-04; 7.7.2.40 NMAC - Rn, 7.7.2.39 NMAC, 03-15-06